A 38-year-old man comes to the emergency department due to 1 day of left-sided chest and neck pain. He could not get comfortable the night before and eventually fell asleep in a semi-recumbent position. He had a sore throat a week ago. Medical history is also significant for acid reflux disease.
Temperature is 37.2 C (99 F), blood pressure is 132/80 mm Hg, and pulse is 90/min. Heart sounds are normal, and lungs are clear to auscultation. There are no skin rashes.
Laboratory results are as follows:
ECG shows sinus rhythm with 1- to 2-mm diffuse ST-segment elevation, except for a 2-mm ST-segment depression in lead aVR. Chest x-ray reveals normal cardiac size and clear lung fields.
Which of the following initial therapies is most likely to cause recurrent symptomatic episodes in this patient?

Question

A 38-year-old man comes to the emergency department due to 1 day of left-sided chest and neck pain.  He could not get comfortable the night before and eventually fell asleep in a semi-recumbent position.  He had a sore throat a week ago.  Medical history is also significant for acid reflux disease.
Temperature is 37.2 C (99 F), blood pressure is 132/80 mm Hg, and pulse is 90/min.  Heart sounds are normal, and lungs are clear to auscultation.  There are no skin rashes.
Laboratory results are as follows:
 ECG shows sinus rhythm with 1- to 2-mm diffuse ST-segment elevation, except for a 2-mm ST-segment depression in lead aVR.  Chest x-ray reveals normal cardiac size and clear lung fields.
Which of the following initial therapies is most likely to cause recurrent symptomatic episodes in this patient?

Quizplus · Accepted Answer

11ec193a_95dd_ef60_853d_194244f9e21b_MD0002_00 This patient's chest pain, characteristic ECG findings of diffuse ST elevations, and mildly elevated troponin are likely due to viral myopericarditis, defined as acute pericarditis with myocardial involvement noted with either elevated cardiac enzymes, myocarditis on cardiac MRI, or newly depressed left ventricular function. Pericarditis and myopericarditis share the same etiologies, which, in developed countries, are largely viral or idiopathic. Other causes include bacterial and fungal infections, autoimmune disease (particularly lupus), neoplasms, end-stage renal disease, and postcardiac injury (Dressler syndrome). Presenting manifestations may include pleuritic chest pain (often after viral infection), heart failure, or arrhythmias. Cardiac MRI and, in rare cases, endomyocardial biopsy may help with diagnosis. Treatment for uncomplicated myopericarditis (normal ejection fraction, no arrhythmias) mirrors that of pericarditis: Nonsteroidal anti-inflammatory drug (NSAID) therapy (eg, aspirin, indomethacin, ibuprofen) is the standard of care to control pain and reduce inflammation and should be started on all patients without contraindications (Choices A and D). In patients with postmyocardial infarction pericarditis, aspirin is the NSAID of choice as other medications may inhibit cardiac scar formation.Colchicine is recommended in conjunction with NSAIDs to improve symptoms and decrease the rate of recurrence (Choice B). Nonsteroidal anti-inflammatory drug (NSAID) therapy (eg, aspirin, indomethacin, ibuprofen) is the standard of care to control pain and reduce inflammation and should be started on all patients without contraindications (Choices A and D). In patients with postmyocardial infarction pericarditis, aspirin is the NSAID of choice as other medications may inhibit cardiac scar formation. Nonsteroidal anti-inflammatory drug (NSAID) therapy (eg, aspirin, indomethacin, ibuprofen) is the standard of care to control pain and reduce inflammation and should be started on all patients without contraindications (Choices A and D). In patients with postmyocardial infarction pericarditis, aspirin is the NSAID of choice as other medications may inhibit cardiac scar formation. Colchicine is recommended in conjunction with NSAIDs to improve symptoms and decrease the rate of recurrence (Choice B). Colchicine is recommended in conjunction with NSAIDs to improve symptoms and decrease the rate of recurrence (Choice B). This patient should receive NSAIDs and colchicine as he has contraindications to neither. By contrast, glucocorticoids, including prednisone, should be avoided as they are associated with a higher rate of recurrence and are only indicated in refractory pericarditis despite NSAID therapy, in patients in whom NSAIDs are contraindicated, or for treatment of a specific underlying cause of pericarditis (eg, autoimmune disease, connective tissue disorders, end-stage renal disease). If an underlying cause is determined, appropriate therapy (eg, antibiotics, antifungals, immunosuppressives) should be initiated. (Choice C) Intravenous immune globulin may maintain long-term remission in corticosteroid-dependent patients with recurrent episodes of pericarditis. Educational objective: Pericarditis and myopericarditis share etiologies and are typically viral or idiopathic in nature. Treatment is directed at the underlying cause, but initial treatment of pericarditis with a combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine is recommended. Glucocorticoids are associated with higher rates of recurrent pericarditis and should be used only in refractory disease, in patients in whom NSAIDs are contraindicated, or for specific underlying causes. __________ References: Efficacy and safety of colchicine for pericarditis prevention. Systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/22442198) International collaborative systematic review of controlled clinical trials on pharmacologic treatments for acute pericarditis and its recurrences. (http://www.ncbi.nlm.nih.gov/pubmed/20934560)

A 38-Year-Old Man Comes to the Emergency Department Due to 1